Dental Clinics, Meeting a Need With No Dentist

A program in Alaska trains dental therapists to provide basic services in communities chronically underserved.

UNALAKLEET, Alaska — The dental clinic in this village on the edge of the Bering Sea looks like any other, with four chairs, a well-scrubbed floor and a waiting area filled with magazines.

But to the Alaska Dental Society and the American Dental Association, the clinic is a place where the rules of dentistry are flouted daily. The dental groups object not because of any evidence that the clinic provides substandard care, but because it is run by Aurora Johnson, who is not a dentist. After two years of training in a program unique to Alaska, Ms. Johnson performs basic dental work like drilling and filling cavities.

Some dentists who specialize in public health, noting that 100 million Americans cannot afford adequate dental care, say such training programs should be offered nationwide. But professional dental groups disagree, saying that only dentists, with four years of postcollegiate education, should do work like Ms. Johnson’s. And while such arrangements are common outside the United States, only one American dental school, in Anchorage, offers such a program.

The number of dentists in the United States has been roughly flat since 1990 and is forecast to decline over the next decade. A study last year from the Centers for Disease Control showed that Americans’ dental health was worsening for the first time since statistics began to be kept.

In Alaska, the A.D.A. and the state’s dental society had filed a lawsuit to block the program that trained people like Ms. Johnson, who are called dental therapists. The groups dropped the suit last summer after a state court judge issued a ruling critical of the dentists. But the A.D.A. continues to oppose allowing therapists to operate anywhere in the lower 49 states. Currently, therapists are allowed to practice only in Alaska, and only on Alaska Natives.

The opposition to therapists follows decades of efforts by state dental boards, which are dominated by dentists, to block hygienists from providing care without being supervised by dentists.

The dental associations say they simply want to be sure that patients do not receive substandard care. But some dentists in public health programs contend that dentists in private practice consider therapists low-cost competition. In Alaska, the federally financed program that supplies care to Alaska Natives pays therapists about $60,000 a year, one-half to one-third of what dentists typically earn.

The Alaska program is small, with fewer than a dozen therapists practicing so far. But the early results are promising, according to dental health experts who are studying the program.

In Unalakleet last month, with a blustery wind blowing off the Bering Sea and the temperature not far above zero, Ms. Johnson was in her clinic, practicing the therapist’s trade on Paul Towarak, a giggly 10-year-old with three cavities.

“Are you trying to laugh? This is not the time to laugh, bud,” Ms. Johnson said to Paul, who wore a bright yellow T-shirt reading “Unalakleet Wolfpack” and blue jeans pocked with holes.

She slipped a drill into Paul’s mouth and bore into one of his cavities, then laid down a filling of silver amalgam. A few minutes later, Paul stood from the chair, smiling broadly. He offered Ms. Johnson a bashful thumbs-up and walked out into the village, a community of 750 people, nearly all Alaska Natives, that can be reached only by plane or snowmobile. Before seeing Ms. Johnson, Paul had received no dental care in four years, a gap not atypical in the Alaskan backcountry, where few dentists want to live and residents are scattered into villages separated by 50 miles or more. With a diet low on fresh vegetables and high on refined sugar, native communities also have high rates of tooth decay. Tales are common of high school students with dentures, and of rural residents who have torn out their own painfully rotten teeth for lack of professional care.

The federally financed program that provides medical care to 136,000 Alaska Natives scattered around the state aims to have 100 fully trained dentists on staff. But it has attracted only 75, and the number of vacancies is growing.

Therapists are a low-cost way to provide care to people who might not otherwise have access to it, according to Dr. Ron Nagel, a dentist and consultant for the Alaska Native Tribal Health Consortium, a nonprofit group financed mostly by federal money that provides medical and dental care to tribal communities. “There’s a huge need for these basic services,” Dr. Nagel said.

After two years of intensive training, the therapists are allowed to perform routine tooth extractions and fill cavities. They must refer more complicated cases, like root canals and complex extractions, to dentists. They must also work under the supervision of a dentist, who reviews their work either in their clinics or off-site, by electronically vetting documents and X-rays.

The Alaska program is expanding slowly. At first, the therapists, including Ms. Johnson, were trained only in New Zealand, because no American dental school offered the two-year program. In 2006, the consortium and the University of Washington created a center in Anchorage to train seven dental therapists a year.

So far, the program appears to be providing high-quality care, according to one study in 2006. The study, by the Baylor College of Dentistry, looked at about 600 procedures in more than 400 patients and found that the quality of procedures performed by therapists was no different from that provided by dentists.

Dr. Kenneth A. Bolin, an assistant professor at Baylor who conducted the review, said the finding did not surprise him. Drilling and filling teeth is relatively straightforward, he said, and the therapists receive at least as much hands-on training in their two-year program as dental students do in four years of dental school.

Dr. Bolin acknowledged that his review was limited because he did not actually examine the teeth of the patients whose charts he reviewed. Still, he said, he saw no reason not to expand the program into the continental United States. As long as therapists are properly trained and supervised, “they can be very effective at addressing the shortage of dental care,” he said.

The American Dental Association does not agree. It says it does not fear lower-cost competition but instead wants to protect patients from inadequately trained therapists, who may not be able to handle the emergencies, like uncontrolled bleeding, that sometimes occur during routine procedures.

“We need to come up with a better, safer solution,” said Dr. Mark J. Feldman, the A.D.A.’s president, who argues that the program has not been adequately studied. Instead of therapists, the A.D.A. is promoting an effort that would train community health aides to help poor people find dentists. The new program will begin this fall, training 18 aides nationwide, according to Dr. Amid I. Ismail, a professor at the school of dentistry at the University of Michigan who has worked with the A.D.A. to devise the program.

Dr. Ismail said the aides would perform triage, determining which patients needed dentists immediately. They will then help the patients make and keep appointments.

For patients who have cavities but whose teeth are not abscessed or otherwise in need of immediate repair or removal, the aides will be trained to apply a temporary fluoride sealant that will slow the rate of decay, Dr. Ismail said. The sealant is an “interim solution,” he said.

But the aides will not be trained to drill and fill teeth. In the long run, the only way to improve dental health is encourage people to take better care of their teeth, Dr. Ismail said.

“I’m not in favor of training just to fill teeth, because a solution of filling teeth is not going to reduce disease,” he said. “The patients will go home, and they will drink six cans of soda a day, and they will come back with more cavities.”

But the therapists and their supporters say the A.D.A.’s program will do little to solve the overall problem of access for people who have untreated cavities and cannot afford to pay the fees that dentists charge — because there simply are not enough dentists who will take Medicaid patients or provide low-cost treatment for patients who cannot afford more.

Since 1990, the number of private dentists has remained roughly flat, at 150,000, even as the United States population has increased 22 percent. As a result, dentists can easily fill their appointment books without seeing people who cannot meet their fees, and patients who have decayed teeth are suffering needlessly, said Tammy Guido, 50, who is one of seven students now training in Anchorage to become a therapist.

“We’re meeting a need that is not being met,” Ms. Guido said.

Alaskan tribal organizations sponsor Ms. Guido and the other students in Anchorage for the program. To be accepted, students must have a high school diploma or equivalency degree; for the newest class, 7 of 18 candidates were accepted.

In interviews, the students in this year’s class all said they were enthusiastic about the chance to serve communities that have little access to care. All seven had quit full-time jobs and must now get by on a $750 monthly stipend during the two years of training.

“Anybody who’s ever had a toothache can tell you it hurts,” said Ben Steward, 24, the only man in this year’s class. “But talk to someone who’s had a toothache for a year.”

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